Inequitable access to aid after the devastating earthquake in Syria
Authors: Munzer Alkhalil, Abdulkarim Ekzayez, Diana Rayes, Aula Abbara
Journal: The Lancet Global Health (2023)

On Feb 6, 2023, a 7·8 magnitude earthquake struck Syria and Türkiye, resulting in the worst natural disaster the region has experienced in the past century. As of March 1, the death toll in both countries has surpassed 51 000 people,1ReutersEarthquake death toll in Turkey rises above 45 000—AFAD.https://www.reuters.com/world/middle-east/earthquake-death-toll-turkey-rises-above-45000-afad-2023-03-01/Date: March 1, 2023Date accessed: March 3, 2023Google Scholar and this number is expected to rise further. The Syrian Assistance Coordination Unit has reported that over 4518 people have lost their lives in northwest Syria,2Assistance Coordination UnitField earthquake updates in Syria.https://acu-sy.org/periodic_imu_reports/syria-earthquake-situation-update/Date accessed: February 19, 2023Google Scholar an area outside the Syrian regime's control in which around 4·5 million people reside, of whom 65% are internally displaced. Additionally, the Syrian Minister of Health has reported 1414 deaths in areas under regime control.3UN OCHASituation report. Syrian Arab Republic—Humanitarian Country Team coordinated response flash update #13—earthquake (as of 18 February 2023).https://reliefweb.int/report/syrian-arab-republic/syrian-arab-republic-humanitarian-country-team-hct-coordinated-response-flash-update-13-earthquake-18-february-2023Date accessed: March 1, 2023Google Scholar The earthquake has compounded the already severe suffering of the Syrian people, who have endured over 12 years of conflict, resulting in over 874 000 casualties and the forced displacement of over half of the pre-conflict population of 22 million people, both internally and abroad.4Alkhalil M Alaref M Mkhallalati H Alzoubi Z Ekzayez A An analysis of humanitarian and health alignment over a decade (2011–2019) of the Syrian conflict.Confl Health. 2022; 16: 57Crossref PubMed Scopus (4) Google Scholar Emergency aid to northwest Syria has been delayed, with negligible search and rescue equipment or supplies arriving in the immediate aftermath, when the likelihood of finding survivors was highest. This delay probably contributed to substantial preventable morbidity and mortality in an already vulnerable population. Zohir Karat, the director of Idlib Health Directorate, announced that until Feb 13, "the amount of aid entered by UN agencies and other donors across the border covered between 5–10% of the needs of hospitals responding to the disaster". Based on a rapid assessment of health facilities in the region, The Health Cluster in Gaziantep estimated that the funding required for a 3-month response to the situation was almost $US30 million;5reliefwebSyria cross-border humanitarian fund: 2023 first reserve allocation—strategy.https://reliefweb.int/report/syrian-arab-republic/syria-cross-border-humanitarian-fund-2023-first-reserve-allocation-strategyDate: Feb 21, 2023Date accessed: March 3, 2023Google Scholar as of Feb 23, 2023, only 19% of this had been secured (unpublished). Following a visit to the Bab Al-Hawa border crossing on Feb 12, UN Under-Secretary-General for Humanitarian Affairs and Emergency Relief Coordinator, Martin Griffiths, acknowledged the UN's failure to aid civilians in the region adequately and pledged to take steps to prevent future negligence.6@UNReliefChief https://twitter.com/UNReliefChief/status/1624701773557469184?t=6CpyYaLEyiPA7bQ-8XJWig&s=08Date: Feb 12, 2023Date accessed: February 18, 2023Google Scholar He later met with the Syrian regime leader Bashar Al-Assad, who agreed to open two new crossings for the entry of aid for 3 months only. Nevertheless, the first UN aid only entered northwest Syria from Bab al-Salama, one of the newly opened crossings, on Feb 14, 8 days after the earthquake.7WHOWHO sends health supplies to reach 400 000 people impacted by earthquakes in Türkiye and the Syrian Arab Republic.https://www.who.int/news/item/10-02-2023-who-sends-health-supplies-to-reach-400-000-people-impacted-by-the-earthquakes-in-t-rkiye-and-the-syrian-arab-republicDate: Feb 10, 2023Date accessed: February 18, 2023Google Scholar As such, the immediate health needs of the population, particularly for the treatment of traumatic injuries, including crush injuries and resulting renal failure, and humanitarian needs, including shelter, food, and water are not being met. An estimated 53 health facilities have been fully or partly damaged, overwhelming the already fragile health system. This damage has compounded the suffering of the population and first responders, for whom the emotional toll is immeasurable, particularly when lives could have been saved if resources had arrived sooner. Furthermore, the earthquake will have both immediate and longer-term impacts on the health system's ability to meet the already high needs for routine clinical care because of the protracted conflict in Syria. By contrast, aid was swiftly delivered to areas under the control of the Syrian regime by the UN. By Feb 15, around 5000 tons of relief and medical aid had been received, including substantial amounts of UN aid.6@UNReliefChief https://twitter.com/UNReliefChief/status/1624701773557469184?t=6CpyYaLEyiPA7bQ-8XJWig&s=08Date: Feb 12, 2023Date accessed: February 18, 2023Google Scholar However, a campaign calling for the lifting of sanctions against the Syrian regime escalated in earnest almost immediately after the earthquake, under the premise that this restricted the entry of aid to regime-controlled areas of Syria. High-income countries, including the USA and the EU constituent countries, had imposed these sanctions against the Syrian regime because of its human rights violations and support of terrorism, with the aim of altering the regime's behaviour. The controversial calls to lift sanctions were eventually heeded by the USA, with the US Treasury Department announcing the suspension of some sanctions for 6 months.8US Department of the TreasuryTreasury issues Syria General License 23 to aid in earthquake disaster relief efforts.https://home.treasury.gov/news/press-releases/jy1261Date: Feb 9, 2023Date accessed: February 18, 2023Google Scholar Some individuals, including the Director-General of WHO,9WHOVirtual Press Conference by WHO Director-General Dr Tedros on response and needs for Syrian Arab Republic and Türkiye earthquakes.https://reliefweb.int/report/syrian-arab-republic/virtual-press-conference-who-director-general-dr-tedros-response-and-needs-syrian-arab-republic-and-turkiye-earthquakesDate: Feb 12, 2023Date accessed: February 18, 2023Google Scholar welcomed this move, while others, including the Chairman of the US House of Representatives Foreign Affairs Committee, were more critical, stating that all sanctions already have exceptions that grant delivery of humanitarian aid. The politicisation of health care and humanitarian aid in Syria will continue to have detrimental effects on already vulnerable communities and equity of access. People across Syria require access to immediate, essential, lifesaving, and sustaining aid and barriers to this must be lifted, particularly for northwest Syria where, in the aftermath of the earthquake, the population has been abandoned. New humanitarian crossings must be established, together with an extension of the 3-month agreement. Without seeking such political solutions, aid will continue to evade a large proportion of Syria's population. As the world looks towards the 2030 Sustainable Development Goals, the emergency response for the earthquake should address the mid-term to long-term needs of the Syrian population through strengthening local systems and paving the way for sustainable recovery. Such an approach requires leadership from the UN and other international organisations to scale up humanitarian funding and ensure the best investment of available resources to northwest Syria, an area which is essentially besieged. This must be done through direct engagement with local humanitarian organisations and quasi-governmental structures, such as the White Helmets and the Health Directorates, as they are best placed to meet the exponential rise in needs after the earthquake and lead the long-term localisation planning. We declare no competing interests.